louisiana pregnancy- associated mortality review 2017 report · 2020-07-29 · review report.5 that...

LOUISIANA

PREGNANCY-

ASSOCIATED

MORTALITY

REVIEW

2017 REPORT

September

2020

Authors:

Jia Benno, M.P.H., Mortality Surveillance Epidemiologist, Louisiana Department of Health (LDH)-Office of Public Health (OPH), Bureau of Family Health (BFH)

Rosaria Trichilo, M.P.H., Statewide Surveillance Manager, LDH-OPH, BFH

Veronica Gillispie-Bell, MD, Medical Director, Louisiana Perinatal Quality Collaborative and Pregnancy-Associated Mortality Review

Chloe Lake, M.P.H., Health Education and Communications Coordinator, LDH-OPH, BFH

Contributors:Lyn Kieltyka, Ph.D., M.P.H., State MCH Epidemiologist LDH-OPH, BFH

Amy Zapata, M.P.H., Director, LDH-OPH, BFH

Jane Herwehe, M.P.H., Data to Action Team Lead, LDH-OPH, BFH

Karis Schoellmann, M.P.H., Communications Team Manager, LDH-OPH, BFH

Dionka Pierce, M.P.H., Program Manager, Data to Action Team, LDH-OPH, BFH

Acknowledgements: This report was made possible through detailed review of maternal death cases by a volunteer review committee. We are deeply grateful to the members of this review committee for their dedication, insight and expertise. We acknowledge the Louisiana Vital Records Office for their collaboration in providing the data used to identify cases of maternal deaths. We thank the health systems, healthcare providers, and coroners who provided the records that allowed meaningful review to occur.

We recognize the Bureau of Family Health Regional Maternal and Child Health Coordinators who abstracted these medical records with care. We also thank our national partners at the U.S. Centers for Disease Control and Prevention’s Division of Reproductive Health and the Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM) program. We acknowledge the Maternal and Child Health Epidemiology Program, Field Support Branch, Division of Reproductive Health, National Center for Chronic Disease Prevention and Public Health Promotion, Centers for Disease Control and Prevention for analytic support and contribution to this report.

Funding for the Louisiana Pregnancy-Associated Mortality Review process is provided through the federal Title V Maternal and Child Health (MCH) Block Grant and the U.S. Centers for Disease Control and Prevention (CDC) ERASE MM Initiative under Grant #NU58DP006683-01. Authorization for the Louisiana Pregnancy-Associated Mortality Review is provided through the Louisiana Commission on Perinatal Care and Prevention of Infant Mortality.

Finally, we honor the women whose experiences we have attempted to understand and learn from here, as well as their partners, children, families, and communities. We hope that the lessons learned from their deaths will help to create new pathways to prevention, health, and equity.

12017 Louisiana Pregnancy-Associated Mortality Review Report

Key Definitions……………………………………………………………………………………………………………………….……………. 3

Introduction………………………………………………………………………………………………………………………………………….4

Executive Summary…………………………………………………………………………………………………..………………………....5 – 6

From Data to Review 7

Verifying and Confirming Maternal Deaths: Review process and criteria……………….…………………………….. 8

Key Findings 9

Snapshot of Pregnancy-Associated Deaths…………………………………………………………………………………………… 10

Racial Disparities in Pregnancy-Associated Mortality……………………………………………………………………………. 11

Racial Disparities: Pregnancy-associated, but not related deaths vs. pregnancy-related deaths…………....12

Maternal Demographics: Insurance type and age………………………………………………………………………………….13

Pregnancy-Related Deaths 14

Contributing Factors: Among pregnancy-related deaths…………………………………………………..………….…15

Pregnancy-Associated, but Not Related Deaths 16

Contributing Factors: Among pregnancy-associated, but not related deaths…..………………..…….………17

Unable to Determine Pregnancy-Relatedness 18

Contributing Factors: Among pregnancy-associated, but unable to determine relatedness deaths...19

Understanding Pregnancy-Associated Deaths: Medical and autopsy records available for review…………20

Understanding Pregnancy-Associated Deaths: Timing of deaths……………………………………………………………21

From Review to Action 22

PAMR Committee Recommendations: Overview…….…………………………………………………………………….…….. 23 – 24

Systems Recommendations…………………………………………………………………………………………………………… 25

Clinical Quality Improvement Recommendations……………………………………………………………………………26 – 27

Social Support Recommendations…………………………………………………………………………………………………..28

Policy Recommendations………………………………………………………………………………………………………………. 29

Current Efforts to Reduce Maternal Mortality………………………………………………………………………………….……33

Appendices and References 33

Appendix A: Acronyms…………………………………………………………………………………………………………………..…..…34

Appendix B: History………………………………………………………………………………………………………………………..…….35 – 36

Appendix C: Data Sources and Methodology: Louisiana pregnancy-associated Mortality Review............ 37 – 38

Appendix D: 2017 PAMR Committee…………………….……………………………………………………………………………… 39 – 40

Appendix E: MMRIA Committee Decisions Form……………………………………………………………….…………………. 41 – 42

Appendix F: Regional Maternal and Child Health Coordinators and Mortality Surveillance Team…….…… 43

Appendix G: Pregnancy Mortality Surveillance System (PMSS) Cause of Death Categorizations…….........44 – 46

Appendix H: Maternal Death Abstraction Form……………………………………………………………………………………. 48 – 49

References…………………………………………………………………………………………………………………………………........... 50 – 51

2

Table of Contents


3

Key Definitions

The following terms will be used throughout the report. All definitions come from the U.S. Centers for Disease Control and Prevention (CDC), in collaboration with key partners in maternal mortality prevention, including the Association of Maternal and Child Health Programs (AMCHP).1

Pregnancy-Associated Deaths1

The death of a woman that occurs during pregnancy or within one year of the end of pregnancy, regardless of the cause. This term encompasses pregnancy-related deaths, pregnancy-associated, but not related deaths, and pregnancy-associated, but unable to determine relatedness deaths, as defined below.

This report focuses on all deaths that meet the criteria for this definition.

Pregnancy-Related DeathPregnancy-Associated,

but Not Related Death

Pregnancy-Associated,

but Unable to Determine

Relatedness

The death of a woman during pregnancy or within one year of the end of pregnancy from a pregnancy complication, a chain of events initiated by the pregnancy, or the aggravation of an unrelated condition by the physiologic effects of pregnancy.

The death of a woman during pregnancy or within one year of the end of pregnancy from a cause that is not related to pregnancy.

A pregnancy-associated death where the cause of death is unable to be determined as “pregnancy-related” or “pregnancy-associated, but not related.”

Example Cause of Death* Example Cause of Death* Example Cause of Death*

Preeclampsia and eclampsia (uncontrolled and extreme high blood pressure during pregnancy leading to serious health complications, including possible organ damage)

Motor vehicle crash (unintentional)

Suicide

*Additional case-specific details beyond cause of death are required to determine which of the three subcategories a pregnancy-associated death falls into. The example causes presented here are not mutually exclusive to the categories they are paired with above.


IntroductionMaternal mortality in Louisiana, 2017

Maternal mortality is a crucial indicator of healthcare quality and gender equity, nationally and internationally.2,3 Studying maternal mortality can help reveal health and social challenges that women of reproductive age experience, and systemic responsiveness to these challenges.2,3 In the United States, maternal mortality is rising, with significant variation by race and ethnicity.1

Collecting, analyzing and comparing maternal mortality data has been challenging to accomplish nationally and locally due to a lack of standard definitions, limited data collection systems, and lack of public investment in reliable processes for case identification and study.4 When interpreting any reported mortality rate or ratio, several factors must be considered:

1. The definition of maternal death used to calculate the mortality rate or ratio (e.g. pregnancy-associated versus pregnancy-related death, within 42 days of pregnancy versus 1 year following the end of a pregnancy).

2. The time period over which the rate is being reported (e.g. single versus multiple year).3. The data source for the identified cases (e.g. cases drawn only from vital records, versus those based on a

committee review).

While surveillance using vital statistics can capture general trends, it is recognized that local review committees are best positioned to comprehensively assess maternal deaths and identify opportunities for prevention.

In 2010, Louisiana Department of Health, Office of Public Health’s Bureau of Family Health established the Louisiana Pregnancy-Associated Mortality Review (LA-PAMR) under the authorization of the Louisiana Commission on Perinatal Care and Prevention of Infant Mortality in order to understand and address maternal mortality in Louisiana. LA-PAMR seeks to establish a strong, reliable, and timely maternal mortality surveillance system in order to inform, guide, and evaluate mortality and morbidity prevention strategies.

LA-PAMR reviews all pregnancy-associated deaths. A maternal mortality review committee (hereafter referred to as “the committee”) was assembled from experts who volunteered their time from March 2018 to December 2019 to complete reviews. The committee focused on all pregnancy-associated deaths, which include pregnancy-related deaths. Findings in this report are therefore presented for all pregnancy-associated deaths verified to have occurred during pregnancy or within 1 year of the end of a pregnancy.


Note on Data Comparisons

Findings from this report are not comparable to findings from the Louisiana 2011-2016 Maternal Mortality Review Report.5 That report compiled findings from an expedited review of only pregnancy-related deaths that occurred during pregnancy or within 42 days of the end of the pregnancy, between 2011 and 2016. This report compiles findings from a comprehensive review of all pregnancy-associated deaths that occurred during pregnancy or within one year of the end of pregnancy in 2017. The two reports use different criteria for what can be considered a pregnancy-related death (42 days after the end of a pregnancy vs. one year after the end of pregnancy). Further, the 2011-2016 report focused on a smaller subset of deaths. Comparisons between the two are discouraged and will likely be invalid.

About Louisiana Pregnancy-Associated Mortality ReviewThe Louisiana Pregnancy-Associated Mortality Review (LA-PAMR) works to quantify and understand pregnancy-associated deaths in order to create actionable, comprehensive recommendations to prevent future deaths. This is accomplished through epidemiological surveillance and multidisciplinary case review (see Appendix D for full list of case review team members). LA-PAMR is an official activity of the Louisiana Commission on Perinatal Care and Prevention of Infant Mortality (Louisiana Perinatal Commission).

Vital records were used to identify maternal deaths, then medical records were used to verify pregnancy at or near the time of death. After the verification process, a review committee conducted in-depth reviews of those cases.

About This ReportThis report summarizes LA-PAMR’s review of 2017 pregnancy-associated deaths and resulting recommendations for prevention. Note: This report has been updated since its original publication in July 2020 to include additional mortality ratios.

Summary of Key Findings The committee reviewed the 65 verified pregnancy-associated deaths which occurred in 2017. This represents a pregnancy-associated mortality ratio of 106.7 deaths per 100,000 births. Of the 65 cases, 15 deaths were pregnancy-related, 41 were pregnancy-associated, but not related; and 9 were pregnancy-associated, but unable to determine relatedness (see definitions on pg. 3).

1. The most common causes of pregnancy-associated deaths were homicide, cardiovascular and coronary conditions, motor vehicle crash, and accidental overdose.

• The top cause of pregnancy-related death was cardiovascular and coronary conditions.• The top causes of pregnancy-associated, but not related death were homicide and motor vehicle

crashes (the same number of deaths were attributed to each cause).• The top cause of pregnancy-associated, but unable to determine relatedness death was suicide.

2. For all pregnancy-associated deaths, black mothers were more than twice as likely to die (2.2 times) as white mothers in Louisiana. This disparity is more prominent in pregnancy-related deaths.

• Among pregnancy-related deaths, over 5 black women (5.6) in Louisiana died for every 1 white woman.

• Among pregnancy-associated, but not related deaths, almost 2 black women (1.9) in Louisiana died for every 1 white woman.

3. Women ages 35 years and older were at an increased risk of pregnancy-related death. Women less than 25 years old were at an increased risk of pregnancy-associated, but not related and pregnancy-associated, but unable to determine relatedness death.

4. The review committee deemed 80% of pregnancy-related deaths to be potentially preventable. 90% of pregnancy-associated, but not related deaths and 100% of pregnancy-associated, but unable to determine relatedness deaths were deemed to be potentially preventable.

Executive Summary Maternal mortality in Louisiana, 2017


Executive Summary Maternal mortality in Louisiana, 2017

6

Summary of Key Findings (continued)5. The PAMR Committee identified contributing factors to deaths across the following levels: patient/family,

provider, facility, systems, and community.

• Provider and facility level factors were the most commonly-identified contributing factors to pregnancy-related deaths, including issues related to lack of continuity of care.

• Patient/family and community level factors were the most commonly-identified contributing factors to pregnancy-associated, but not related deaths. These included Substance Use Disorder (SUD) (patient/family level) and lack of resources for anger management, conflict resolution, social skills training, and stigma or fear surrounding SUD (community level).

• Patient/family, provider and facility level factors were the most commonly-identified contributing factors to pregnancy-associated, but unable to determine relatedness deaths. These included mental health conditions (patient/family level), lack of referrals to mental/behavioral health or substance use treatment (provider level), and lack of continuity of care/care coordination (facility level).

6. Autopsies were performed in about two-thirds (68%) of cases. About 1 in 3 (34%) cases were missing at least some records crucial to case review.

Summary of RecommendationsRecommendations represent committee consensus following a critical review of each of the 65 deaths, and were drawn from both individual case reviews and overall data and findings. They are classified by point of intervention: systems, clinical quality improvement, social support, and policy. However, five overarching needs or themes emerged consistently throughout review:

• Improve care coordination before, during, and between pregnancies.• Ensure pregnant women receive the appropriate level of care based on the complexity and severity of their

medical issues and risk factors present. • Expand the obstetric healthcare workforce to include cardiology, psychiatric and addiction specialists.• Improve and expand identification of, and treatment for, substance use during pregnancy. • Address racial and cultural bias across the network of care that serves pregnant and postpartum women

(including hospitals, Emergency Medical Services, physician offices, and community clinics), as well as the institutions that influence or coordinate with that network (including public health agencies, Medicaid, and coroners).


From Data to Review

Maternal Mortality in Louisiana, 2017


8

Verifying and Confirming Maternal DeathsReview process and criteria

In 2017, 92 potential pregnancy-associated deaths were identified using Vital Records data alone. Bureau of Family Health Regional Maternal and Child Health (MCH) Coordinators verified that 65 of the 92 identified deaths had a documented pregnancy at the time of death or within one year of death. The remaining 27 deaths were classified as false cases and not considered eligible for review. The PAMR committee determined that 15 of the 65 verified deaths were pregnancy-related, 41 were pregnancy-associated, but not related, and 9 were pregnancy-associated, but unable to determine relatedness. The committee used the Building U.S. Capacity to Review and Prevent Maternal Deaths project’s Maternal Mortality Review Information Application’s (MMRIA) Committee Decisions Form (version 14) to classify each case (see Appendix E).

92 Identified Deaths

Identified deaths met the following criteria:• Louisiana resident at the time of death, and death occurred in Louisiana• Between the ages of 10 and 55 years at the time of death• Identified as having been pregnant at the time of death or within the preceding year by linkage of the

death certificate to a corresponding live birth or fetal death certificate or inpatient hospital discharge record, indication of pregnancy status on the death certificate through the pregnancy checkbox, or cause of death had an ICD-10 code of A34, O00-O99 (causes related to pregnancy, childbirth, or complications during the postpartum period).

65 Verified Deaths

Pregnancy-associated deaths met the below criteria:• Documentation in medical records and/or

coroner reports of a pregnancy at the time of death or within one year of death

27 False (Unvalidated) Cases

These cases met the definition of a potential pregnancy-associated death based on the cause of death listed on death certificates, but could not be validated through medical records and/or coroner reports.

There was either no record of any pregnancy or there was a documented pregnancy that ended more than one year before death. See “Data Limitations” in Appendix C for more details.

Cases Reviewed by Committee

Committee determinations: • 41 pregnancy-associated, but not related cases• 15 pregnancy-related cases• 9 pregnancy-associated, but unable to

determine relatedness cases

Cases reviewed by Regional Maternal & Child Health Coordinators

These cases were ineligible for further review

STOP

Use of Vital Records death data alone is not enough

to identify true pregnancy-associated deaths


Key Findings



1

22

1

3

6

11

1

22

3

710

410

11

31

11

Amniotic Fluid Embolism

Autoimmune Diseases

Seizure Disorders

Liver and Gastrointestinal Conditions

Unknown Cause of Death

Fire/Burns

Embolism

Preeclasmpia and Eclampsia

Pulmonary Conditions

Infection

Malignancies

Suicide

Cardiomyopathy

Accidental Overdose

Motor Vehicle Crash (MVC)

Cardiovascular and Coronary Conditions

Homicide

Pregnancy-Associated,but Not Related

Pregnancy-Associated,but Unable to DetermineRelatedness

Causes of DeathAs determined by the PAMR Committee

1

Pregnancy-Related

23%

14%

Pregnancy-Associated,

but Not Related

63%

Breakdown of Pregnancy-RelatednessOf the 65 deaths reviewed, the committee determined:

• 15 deaths (23%) were pregnancy-related.*

• 41 deaths (63%) were classified as pregnancy-associated,

but not related.*

• 9 deaths (14%) were classified as pregnancy-associated,

but the committee was unable to determine relatedness.

*See page 3 for definitions

10

Snapshot of Pregnancy-Associated Deaths

Key Points• Nearly 1 in 4 (23%) deaths were determined to be pregnancy-related. • Pregnancy-associated, but not related deaths accounted for the majority of deaths (63%).• The leading causes of pregnancy-associated deaths were homicide (17%), Cardiovascular and Coronary

Conditions (17%), and Motor Vehicle Crash (MVC) (15%).

In 2017, Louisiana had 65 pregnancy-associated deaths. This represents

a pregnancy-associated mortality ratio of 106.7 deaths per 100,000 births.

Pregnancy-Associated, but Unableto DetermineRelatedness


Pregnancy-Related

38% 60%

Non-Hispanic white Non-Hispanic black

2%Non-Hispanic, other race

11

Racial Disparities in Pregnancy-Associated Mortality

Pregnancy-Associated Mortality by RacePregnancy-associated deaths can happen to women of any race. However, some women are disproportionately affected.

For all pregnancy-associated deaths, black mothers were more than

twice as likely to die (2.2 times) as white mothers in Louisiana.

Key Points• Racial disparities in maternal mortality are complex and due to many factors. Mortality is influenced by a

wide range of economic, social, and clinical determinants. Some of those factors are directly related to pregnancy and birth itself, including health status prior to pregnancy and consistent access to quality healthcare during pregnancy and throughout the life course. Other, broader factors that contribute to adverse outcomes (including death), include social determinants of health such as racial bias and discrimination, lack of transportation or childcare, poverty, and racism in policies, practices and systems.8,9

More than 2 black women in Louisiana died…

…for every 1 white woman80.0

174.1


Pregnancy-Associated Mortality by Race (per 100,000 births)

However, non-Hispanic black mothers accounted for 60% of all pregnancy-associated deaths that occurred in 2017.

37% of all births in Louisiana in 2017 were to non-Hispanic black women.6


54.4

102.7


Key Points• For pregnancy-associated, but not related deaths, black women died at almost twice the rate of white

women. Homicide was a top cause. • For pregnancy-related deaths, black women died at five times the rate of white women. Complications from

hypertensive emergencies contributed to this disparity. • Implicit bias and systemic racism drive racial disparities in health and healthcare.10 Louisiana’s health

disparities demonstrate the need to continue efforts to address these issues at the provider and facility level to ensure equitable care.

• Social determinants of health such as food insecurity, intimate partner violence, lack of safe housing and lack of educational support contribute to disparities in all pregnancy-associated deaths.8, 9, 10

Disparities in Pregnancy-Related Deaths

Over 5 black women in Louisiana died…

…for every 1 white woman9.6

53.6


Pregnancy-Related Mortality by Race (per 100,000 births)

12

Racial DisparitiesPregnancy-associated, but not related deaths vs. pregnancy-related deaths

Almost 2 black women in Louisiana died…

Disparities in Pregnancy-Associated, but Not Related Deaths

…for every 1 white woman

Pregnancy-Associated, but Not RelatedMortality by Race (per 100,000 births)

Significant racial disparities exist among all pregnancy-associated deaths.

However, these disparities are more prominent in pregnancy-related deaths.


10.0

84.8

34.932.0

58.7

5.3

20.8

69.3

0

52.1

39.1

13.0

Pregnancy-Related(15 deaths)

Pregnancy-Associated, but Not Related (41 deaths)

Unable to Determine Relatedness (9 deaths)

25-29 30-34< 25 35+ 25-29 30-34< 25 35+ 25-29 30-34< 25 35+

13

Maternal DemographicsInsurance type and age

Key Points• Medicaid covers the majority of pregnancies and births in Louisiana. This presents opportunities to optimize

services covered by Medicaid to ensure quality healthcare before, during, and after pregnancies, and to provide coordinated care between pregnancies to prevent pregnancy-associated deaths.

• Pregnancy-associated, but not related deaths and pregnancy-associated, but unable to determine relatedness deaths disproportionately affect younger women (less than 25 years of age), while pregnancy-related deaths disproportionately affect among women over 35 years old. The top cause of death for pregnancy-associated, but not related deaths among women under age 25 was homicide, while the top cause of pregnancy-associated, but unable to determine relatedness deaths for women under age 25 was suicide.

33 Pregnancy-Associated

Mortality Ratios by AgeMortality ratios below are deaths per 100,000 births. The age distribution of women who died is different for pregnancy-related deaths versus the two other categories of pregnancy-associated deaths. Women ages 35 years and older were at an increased risk of pregnancy-related death. Women less than 25 years old were at an increased risk of pregnancy-associated, but not related and pregnancy-associated, but unable to determine relatedness death. .

Insurance Type68% of women who died had health insurance through Medicaid. The majority of Louisiana women (63%) who were pregnant or gave birth in 2017 had health insurance through Medicaid.11

68% 11% 20%

Medicaid Private Unknown

1% Self-Pay


Obesity, Mental Health Conditions and Substance Use

20% 13% 47% 20%

No Chance Good ChanceSome ChanceUnable to Determine

Pregnancy-Related Deaths15 deaths (24.6 deaths per 100,000 births)

14

Key Points

• Preventability assessments help prioritize future areas of intervention and action. • Determination of preventability is based on consensus achieved by the maternal mortality review committee.• Louisiana committee findings suggest that deaths due to leading causes are highly preventable.

Preventability & Chance to Alter OutcomesThe committee reviewed all deaths and used the MMRIA Committee Decisions Form (see Appendix E) to determine their preventability and the chance to alter the outcome of each case. A death was considered preventable if the committee determined that there was any chance* the death could have been averted by making one or more reasonable changes to patient, family, provider, facility, system, and/or community factors. “Unable to Determine” cases were considered preventable, but the degree of preventability was unable to be determined.

*Any chance to alter the outcome includes the MMRIA Committee Decisions Form categories: “Some Chance,” “Good Chance,” and “Unable to Determine.”

A pregnancy-related death refers to the death of a woman during pregnancy or within one year of the end of pregnancy from a pregnancy complication, a chain of events initiated by the pregnancy, or the aggravation of an unrelated condition by the physiologic effects of pregnancy.

80% of pregnancy-related deaths were considered potentially preventable.

33%

13% 7% 7%7%20%

7%

47%

73%86%

Obesity Mental Health Conditions

Substance Use


The top underlying causes of death within this category were

cardiovascular and coronary conditions (6 deaths), cardiomyopathy (3 deaths), preeclampsia and eclampsia (2 deaths) and embolism (2 deaths)

The committee determined if these three conditions (as specified by the MMRIA Form – see Appendix E) contributed to each death. Regardless of individual-level factors, health systems can work to ensure all people have the safest pregnancy, birth, and postpartum experiences possible.

Yes Probably

Unknown No

Provider and facility level factors were the most commonly-identified

contributing factors to pregnancy-related deaths.

15

Review committee members identified contributing factors to pregnancy-related deaths using the MMRIA

Committee Decisions Form (see Appendix G). Contributing factors included any behavior or systems issue which

increased the severity of morbidity or the likelihood of mortality.12 These factors did not necessarily cause the

fatal outcome but may have been among a number of factors that led to the death. Contributing factors can be

analyzed to develop and guide quality improvement efforts.

Each contributing factor identified through review committee discussion was categorized into 1 of 5 levels: patient/family, provider, facility, system, and community (see Appendix G for more details).

Contributing FactorsAmong pregnancy-related deaths

6 deaths (40%)Presence of complex chronic disease with need for primary care and tailored reproductive life planning

Top Contributing Factors: Patient/Family LevelCompleteness of medical records and availability of relevant information often limited the review committee’s ability to assess for patient/family level contributing factors.

Top Contributing Factors: Provider and Facility LevelContributing factors are not mutually exclusive – a death may have more than one of the following factors. In almost two-thirds (60%) of pregnancy-related deaths, a lack of continuity of care influenced the death.

40%

53%

60%Lack of Continuity of Care*

(9 deaths)

Clinical Skill/Quality of Care(8 deaths)

Inadequate Assessment of Risk(6 deaths)

7 deaths (46%)Patient or family members did not have necessary knowledge to identify symptoms/events that required treatment and follow-up.

*Lack of continuity of care category included: not providing a cardiovascular consult; the decedent being seen by multiple doctors but no communication between them; and failure to admit patient to the hospital when outpatient management fails.


Key Points

• Motor vehicle crashes and homicide were the leading causes of pregnancy-associated, but not related death.• Substance use contributed or probably contributed to 1 in 4 (27%) pregnancy-associated, but not related

deaths. Universal screening for mental health issues and Substance Use Disorders is recommended as a first step to identify women who need treatment and services.13



Pregnancy-Associated, but Not Related Deaths41 deaths

16

A pregnancy-associated, but not related death refers to the death of a woman during pregnancy or within one year of the end of pregnancy from a cause that is not related to pregnancy.

90% of pregnancy-associated, but not related deaths

were considered potentially preventable.

10% 12% 59% 19%

No Chance

Good ChanceSome ChanceUnable to Determine

12% 12%20%

0% 7% 7%3%20%

2%

85%

61%71%


Substance Use


Yes Probably

Unknown No

The top underlying causes of death within this category were homicide (10 deaths), motor vehicle crash (10 deaths) and unintentional overdose (7 deaths)



Key Points• Screening for and treatment of Substance Use Disorders can prevent a significant proportion of deaths.14

• Patient education around health and safety issues, such as wearing seatbelts, plays a role in preventing pregnancy-associated deaths. Education must be appropriate for all health literacy levels.

• Addressing mental health conditions in pregnant individuals and the general population may improve maternal outcomes.

• Community resources that assist people with anger management and conflict resolution are needed to help reduce and prevent interpersonal violence.

• Lack of adherence to laws regarding access to firearms contributes to pregnancy-associated deaths.

Patient/family and community level factors were the most

commonly-identified contributing factors to these deaths.

17

Contributing FactorsAmong pregnancy-associated, but not related deaths

Top Contributing Factors: Community LevelIn almost one third (29%) of deaths, lack of community resources or outreach for issues related to anger management, conflict resolution, social skills training, and stigma/fear surrounding SUD contributed to the death.

Top Contributing Factors: Patient/Family LevelContributing factors are not mutually exclusive – a death may have more than one of the following top contributing factors. In almost one third (29%) of deaths, the woman or someone in her immediate family had a Substance Use Disorder (SUD) that influenced the death.

22%

27%

29%Substance Use Disorder (SUD) of

decedent or family member (12 deaths)

Lack of adherence to medical recommendations or health & safety laws,

such as wearing seatbelts (11 deaths)

Mental health conditions of the decedent or family members (9 deaths)

7%

12%

29%Lack of community resources or

outreach to address key social issues(12 deaths)

Delayed or inadequate law enforcement response (e.g. delayed restraining orders)

(5 deaths)

Access to firearms* (3 deaths)

*This was a write-in category, which allows the review committee to capture factors not listed on the MMRIA Committee Decisions Form. If it had been a pre-existing option, this contributing factor may have been identified in additional cases

Completeness of medical records and availability of relevant information often limited the review committee’s ability to assess for patient/family and community-level contributing factors.


22%

56%

11%11%

33%

11% 11%

78%

22%

45%


Substance Use

45% 45% 10%

Good ChanceSome ChanceUnable to Determine

For 9 out of 65 pregnancy-associated deaths, the committee was unable to determine pregnancy-relatedness (i.e. if the death occurred due to a pregnancy complication, chain of events initiated by pregnancy, or the aggravation of an unrelated condition by the physiologic effects of pregnancy).

Unable to Determine Pregnancy-Relatedness9 deaths

18

Key Points

• One third (33%) of pregnancy-associated, but unable to determine pregnancy-relatedness deaths were suicides. Other known causes of death included homicide, liver and gastrointestinal conditions, cardiomyopathy, and cardiovascular and coronary conditions.

The top underlying cause of death within this category was suicide.

100% of pregnancy-associated, but unable to determine relatedness

deaths were considered potentially preventable.




Yes Probably

Unknown No



0% 0%

Patient/family, provider and facility level factors were the most

commonly-identified contributing factors to these deaths.

19

Contributing FactorsAmong pregnancy-associated, but unable to determine relatedness deaths

Top Contributing Factors: Provider and Facility LevelIn two-thirds (67%) of these deaths, lack of referrals to treatment for mental/behavioral health conditions or substance use influenced the death. In over half (56%) of these deaths, lack of continuity of care or adequate care coordination influenced the death.

Top Contributing Factors: Patient/Family LevelContributing factors are not mutually exclusive – a death may have more than one of the following top contributing factors. In two-thirds (67%) of these deaths, mental health conditions influenced the death. In over half (56%) of these deaths, the woman or someone in her immediate family had a Substance Use Disorder that influenced the death.

33%

56%

67%Lack of referrals to mental/

behavioral health or substance use treatment (6 deaths)

Lack of continuity of care/care coordination (5 deaths)

Lack of standardized policies or procedures for screening & follow-up

for mental health and postpartum depression (3 deaths)

Key Points• Efforts to prevent these deaths can occur on several levels, including patient/family, provider, and facility level.• Overwhelmingly, on multiple levels, mental health conditions and substance use contribute to pregnancy-

associated deaths and must be addressed.

Completeness of medical records and availability of relevant information often limited the review committee’s ability to assess for patient/family and community-level contributing factors.


33%

33%

56%

67%Mental health conditions (6 deaths)

Substance Use Disorder of the decedent or family (5 deaths)

Childhood abuse or trauma (3 deaths)

Patient and family did not have necessary knowledge to identify symptoms/events that required

treatment and follow-up (3 deaths)

31% 35% 32%Complete Mostly Complete Somewhat Complete Not

Complete2%

Understanding pregnancy-associated deaths requires information from multiple types of records, including those from medical/health systems, law enforcement, mental/behavioral health providers and systems, and government or social service agencies. Records can be difficult to obtain due to:

• Lack of information or data sharing agreements and processes in place across and within these systems.Example: Medical record sharing across health networks can be limited

• Legal restrictions and policies that regulate what information agencies can share.Example: It is difficult to obtain records related to a death that is part of an ongoing criminal investigation

• Reluctance or hesitation to share copies of records obtained from external agencies. • Staff turnover which hinders collaboration and information sharing between and across agencies or systems.

Key Points• Data sharing across and within systems and agencies for the purpose of maternal mortality review would

improve the review committee’s access to needed records (e.g. records related to or from prenatal care, mental health, Medicaid, etc.). Access to records would allow for a more complete understanding of deaths.

• Improved understanding of the causes and circumstances surrounding pregnancy-associated deaths is needed to direct quality improvement efforts and ensure effective resource allocation to prevention efforts. Autopsies and the availability of complete records for review are vital to this process.

Autopsies

• Autopsies reveal information that helps establish cause of death. Without an autopsy, it is challenging to determine the immediate and underlying cause of death in certain scenarios.

• Autopsies were performed on 68% of deaths.

Yes68%

No32%

Completeness of Records for ReviewAccess to complete records is critical to determine factors that contributed to pregnancy-associated deaths, and to determine their preventability. 20 out of 65 cases were determined by the committee to have complete records available for review.

*Approximately one-third (22 cases) were identified as having either “somewhat complete” or “not complete” records, meaning that information crucial to the review of the case was not available to the review committee(see Appendix E for full definitions of complete, mostly complete, somewhat complete and not complete).

Autopsies were performed in about two-thirds (68%) of cases.

About 1 in 3 of cases were missing at least some* records

crucial to case review.

20

Understanding Pregnancy-Associated DeathsMedical and autopsy records available for review


Key Points• The majority (80%) of pregnancy-related deaths occurred during or within 42 days of pregnancy. • Two thirds (66%) of pregnancy-associated, but not related deaths occurred 43 days to 1 year after pregnancy

and were most frequently due to homicides.• Two thirds (67%) of pregnancy associated, but unable to determine relatedness deaths occurred 43 days to

1 year after pregnancy and were most frequently due to suicide.

Timing of pregnancy-associated, but not related deaths

Timing of pregnancy-related deaths

The majority (80%) of pregnancy-related deaths occurred

during or within 42 days of pregnancy.

21

Understanding Pregnancy-Associated DeathsTiming of deaths


Timing of pregnancy-associated, but unable to determine relatedness deaths

• Deaths occurring within 42 days of pregnancy were most frequently due to cardiovascular and coronary conditions.

• Deaths occurring 43 days to 1 year after pregnancy were most frequently due to cardiomyopathy.

• Deaths occurring during pregnancy were most frequently due to motor vehicle accidents.

• Deaths occurring 43 days to 1 year after pregnancy were most frequently due to homicide.

• Deaths occurring 43 days to 1 year after pregnancy were most frequently due to suicide.

27%While pregnant

53%Within 42 days of

pregnancy

20%43 days to 1 year after pregnancy

27%While pregnant

7%Within 42 days of pregnancy


22%While pregnant

11%Within 42 days of pregnancy


From Review to Action



PAMR Committee RecommendationsOverview

Louisiana’s PAMR Committee generated the following recommendations through their review of 2017 maternal deaths. Recommendations represent committee consensus following a critical review of each of the 65 deaths. Committee reviews were guided by the U.S. Center for Disease Control and Prevention (CDC)’s Maternal Mortality Review Information Application’s (MMRIA) Committee Decisions Form. This form asks committee members to use their expertise to answer the question “If there was at least some chance that the death could have been averted, what were the specific and feasible actions that, if implemented or altered, might have changed the course of events?” (see Appendix E). The recommendations are drawn from both individual case reviews and overall data and findings from all 65 deaths.

Recommendations are categorized by point of intervention: systems, clinical quality improvement, social support, and policy. Individuals and organizations working at each of these levels can use these recommendations to help inform and guide their efforts to improve maternal health outcomes.

Five overarching needs or themes emerged consistently throughout reviews:

Improve care coordination before, during, and between pregnancies. Care coordination is defined by the Agency for Healthcare Research and Quality as “the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of healthcare services.”17 Existing medical conditions and social determinants of health can impact pregnancy outcomes, which means that women often require care from several providers, not just an obstetrician. Maternal care coordination requires all providers to communicate with each other about a patient’s care, and ensures patients are linked to non-medical resources such as supports for housing, education, and economic stability. Maternal care coordination has been shown reduce preterm births,18 improve use of perinatal services,19 and improve contraception use for the purpose of healthy birth spacing.20 The PAMR Committee identified lack of care coordination as a contributing factor in multiple deaths.

Ensure pregnant women receive the appropriate level of care based on the complexity and severity (acuity) of their medical issues, and risk factors present. Health complications during labor, delivery, and the year after birth are more likely when medically high-risk patients are cared for at facilities designed to serve low-acuity patients (i.e. patients who do not experience severe illness or injury).21

The PAMR Committee identified a lack of risk-appropriate care as a contributing factor in multiple deaths. Facilities at all levels can improve their readiness to care for patients who experience severe complications or illness by performing risk assessments on all patients and implementing evidenced-based practices to support patient safety. Best practices include the Alliance for Innovation on Maternal Health’s Patient Safety Bundles focused on Obstetric Hemorrhage, Severe Hypertension in Pregnancy, Maternal Mental Health, Maternal Venous Thromboembolism, Reduction of Peripartum Racial/Ethnic Disparities, and Obstetric Care for Women with Opioid Use Disorder.22

Expand the obstetric healthcare workforce to include cardiologists, psychiatric and addiction specialists. Left untreated, cardiac, psychiatric and substance use disorders can negatively impact maternal and child health.23, 24 The PAMR Committee identified lack of access to healthcare providers in these areas as a contributing factor to multiple deaths. Multidisciplinary teams are needed to address the multiple medical issues seen in maternity care. To improve maternal outcomes and decrease maternal mortality, the obstetric workforce cannot be limited to obstetric providers.


Address racial and cultural bias across the network of care that serves pregnant and postpartum women (including hospitals, Emergency Medical Services, physician offices, and community clinics), as well as the institutions that influence or coordinate with that network (including public health agencies, Medicaid, and coroners). Implicit bias and structural racism contribute to maternal mortality.25 Implicit bias must be addressed at all levels of the healthcare system. Structural racism must be addressed within all systems that coordinate or impact care for women, including but not limited to public health agencies, health insurance providers/payors, and legislative or policymaking bodies.

Improve and expand identification of and treatment for substance use during pregnancy. The PAMR Committee identified Substance Use Disorder (SUD) as a leading contributing factor for multiple deaths. In particular, review of pregnancy-associated, but not related and pregnancy-associated, but unable to determine relatedness deaths reveal a lack of screening with a validated tool for SUD. Though Medication Assisted Treatment (MAT) for opioid use disorder is the standard of care,26 case reviews indicated that women with SUD did not receive this course of treatment.


PAMR Committee RecommendationsOverview


Expand the obstetric healthcare workforce• Health systems should work to integrate more cardiologists, psychiatrists, and addiction specialists

into women’s health and obstetric care.• Health systems should employ telehealth as a strategy to improve access to obstetric care

(including care for high-risk patients), especially in rural areas.

Address racial and cultural bias• Provide implicit bias training to direct service providers, social service or public health program

managers, coroners, and agency and institutional leadership across multiple systems of care.

Improve systems of care and ensure appropriate level of care• Health systems should ensure that patients receive care from providers or facilities that are

equipped to provide the appropriate level of medical care during childbirth, based on patient needs and risk factors. Health systems should ensure safe and streamlined transfer of critically ill patients to new facilities and providers when necessary.

• Implement a “Community Paramedicine” Model.27 This healthcare model is one in which Emergency Medical Services (EMS) provide select primary care services in addition to emergency medical care.

Improve care coordination• Health systems should invest in care coordinators to work within and across facilities, including

across departments (e.g. primary care, emergency department, obstetrics and more), to help improve patients’ general health and control chronic health conditions prior to, during, and after pregnancy.

• Cancer affects maternal health outcomes. Health systems and payors should ensure that all women, regardless of insurance type, have access to and are encouraged to use preventive medical care throughout their lives, especially cancer screenings.

• Birthing and medical facilities need to work with other systems – such as home visiting services, Federally Qualified Health Centers, and correctional facilities – to establish pathways to facilitate the exchange of health information.

• Health systems should develop referral mechanisms and networks to help obstetric care providers connect or refer patients to high quality resources for mental health, violence prevention, substance use, housing assistance, economic support, and other medical and non-medical needs.

• Health systems should ensure postpartum care coordination and timely follow-up for women who experienced complex pregnancies or critical illness during childbirth.

Systems

PAMR Committee RecommendationsSystems

Address substance use before, during and after pregnancy• Educate providers and staff on the benefits of Medication Assisted Treatment (MAT) over

abstinence during pregnancy as a strategy to improve patient access to MAT.• Needle exchange programs, shelters, and substance use treatment programs should offer easy-to-

access pregnancy testing.• The legal system should explore the practice of sentencing women with drug-related charges to

Substance Use Disorder (SUD) treatment or diversion programs instead of incarceration or fines.


Promote Community Health and Safety

• The Highway Safety Commission should integrate education on appropriate seat belt use by

pregnant women into existing child passenger safety training courses.

• Motor vehicle crash prevention programs and campaigns should use state-level data to inform

interventions that address the risk of drowsy driving.

Systems

PAMR Committee RecommendationsSystems

Improve systems of care and ensure appropriate level of care

• Every time women interact with healthcare systems, providers (including non-obstetric providers)

should offer them reproductive life planning counseling. Counseling should be informed by an

assessment of an individual’s risk of pregnancy complications due to chronic disease. Providers

should counsel women on a full range of contraceptive options and how to access them, especially

when pregnancy is contraindicated.

• Obstetric care providers should counsel patients and families around pregnancy risk factors

related to family history (i.e. risks related to genetic disorders).

• Healthcare providers should screen women with a history of venous thromboembolism for

thrombophilia prior to pregnancy to inform appropriate preventative measures.

• Obstetric care providers should implement the Alliance for Innovation on Maternal Health

Program’s Maternal Venous Thromboembolism Patient Safety Bundle.16

• Quality improvement review should occur at the facility level to ensure provider adherence to

standards of care for managing hypertension and assessing cardiac risk during pregnancy.

• Facilities should implement a Maternal Early Warning Signs protocol to improve recognition and

treatment of sepsis.

• Obstetric care providers should exercise shared decision-making with patients and their families

regarding pregnancy management, especially when it is not medically recommended to continue

the pregnancy.

• Train obstetric care providers to use a standardized tool to screen for Intimate Partner Violence

(IPV), and to recognize the warning signs of IPV. For patients with a positive screen, referral

pathways to services should be readily available to providers.


Improve care coordination

• Pregnant and postpartum women can benefit from family support and coaching programs,

including home visiting programs. Providers and care coordinators should be familiar with the

eligibility requirements, enrollment timelines, and referral processes for these programs.

• When postpartum women are discharged from the hospital, obstetric providers should educate

women and their families on warning signs by using tools, such as a post-birth checklist, to help

families understand which signs might indicate a problem and require medical attention. This is

especially important for postpartum women with hypertensive disorders (high blood pressure).

• Obstetric providers should ensure postpartum care coordination with cardiology services for

women diagnosed with a hypertensive disorder in pregnancy, as these women have a long-term

increased risk of cardiovascular disease.15

• Emergency Medical Service (EMS) providers should receive education and training to recognize

and treat obstetric emergency conditions, such as hypertensive disorders of pregnancy.

• Health systems and emergency departments should create processes to ensure appropriate

follow-up for pregnant and postpartum patients after emergency department visits, whether

those visits are related to pregnancy or not.

PAMR Committee RecommendationsClinical Quality Improvement

Clinical Quality Improvement


Address racial and cultural bias• Health systems should provide physicians, nurses, advanced practice providers, and other

clinicians with training related to racial bias and related health outcomes. • Obstetric care providers and other healthcare professionals should receive training to provide

compassionate, quality care to people experiencing high-risk pregnancies, regardless of comorbid conditions (e.g. SUD).

Address substance use before, during and after pregnancy• Women with SUD need prenatal and primary care that includes MAT and the full spectrum of

contraceptive options. Partner with national organizations to train women’s healthcare providers to integrate MAT into prenatal and primary care.

• Behavioral health screening should occur as the standard of care during each patient encounter.• Emergency room providers should receive training to help them recognize SUD and polypharmacy

(simultaneous use of multiple drugs), and to better understand their role in preventing substance use and abuse, especially for perinatal patients.

• When substance use overdose occurs, health systems should implement targeted case management.

Clinical Quality Improvement

PAMR Committee RecommendationsClinical Quality Improvement

Improve systems of care and ensure appropriate level of care (continued)• Obstetric care and emergency departments should coordinate to improve recognition of

pregnancy and postpartum conditions diagnosed in the emergency department that require referral to obstetric care services.

• Obstetric providers and prenatal classes should teach patients/participants how to correctly use seatbelts during pregnancy. This is especially important for women with increased Body Mass Index (BMI), since they are at an increased risk for death or severe injury due to a motor vehicle crash.28

29

Improve systems of care and ensure appropriate level of care• Ensure existing programs and services that provide social support during pregnancy (doula

services, home visiting programs, etc.) are covered by all insurance providers. Review eligibility criteria and capacity limitations of existing programs, and explore ways to make these programs accessible to all women.

• Quality improvement review should occur at the health system level to identify barriers to mental health screening and referral, particularly for postpartum depression, IPV, and SUD.

• Support and fund interventions designed to stop the cycle of IPV by focusing on perpetrators. Interventions and resources include anger management counseling or classes, mental health services, and healthy relationship coaching.

Expand the obstetric healthcare workforce• Expand mental health provider workforce to ensure pregnant and postpartum women have

access to inpatient and outpatient psychiatric care. Inpatient psychiatric facilities should modify their policies to allow pregnant women to be admitted.

Address substance use during pregnancy• Increase family awareness of how to use Narcan (naloxone), a nasal spray that can help reverse

an opioid overdose.


Improve care coordination• Train a wide range of social service providers – including home visiting programs; Special

Supplemental Nutrition Program for Women, Infants and Children (WIC); community behavioral health supports; and more – to counsel women around reproductive life planning and refer women to services as needed.

• Facilities should consider hiring social services navigators to coordinate services that address social determinants of health. Navigators would ensure the patient was informed about both the service and the referral, and confirm the patient was connected to the service.

• In cases of adoption, adoption facilitators should ensure birth mothers are connected to mental health services or other emotional support resources.

• When families have suffered a loss, providers should connect families to bereavement support and services.

• Women and families would benefit from hospital-based referrals to counseling and supportive services for end of life planning, home hospice and palliative care.

Social Support

PAMR Committee RecommendationsSocial Support

Promote community health and safety• Identify and integrate mental health providers that offer community-based services for pregnant

and postpartum women and families into care networks. Community-based services include support for IPV survivors (including children), MAT, and depression/suicide prevention.

30

Promote community health and safety (continued)• Create or expand referral mechanisms and networks to help obstetric care providers connect

pregnant and postpartum women to community-based mental health resources. This may be both particularly challenging and important in rural areas.

• Health systems should partner with community-based organizations to address social determinants of health that impact maternal outcomes, such as food insecurity, safe housing, and education.

• Develop education campaigns to teach and promote bystander CPR education.• Conduct research to identify barriers to accessing health services through a primary care network

in order to decrease the use of emergency departments as a first line method of care. • Community programs should implement interventions or campaigns to reduce stigma towards

individuals with mental health conditions, especially those who are also pregnant or parents. • Home visiting program providers should be trained to recognize signs of IPV and warning signs for

suicide. • Employers should educate employees about the signs of fatigue and the risks of drowsy driving

following long shifts or during nontraditional work hours.


Social Support

PAMR Committee RecommendationsSocial Support

Policy

Improve systems of care and ensure appropriate level of care• Postpartum women, especially those who are medically high-risk, can benefit from nurse home

visits after delivery. Nurse home visits should be covered by insurance. • Obstetric care providers should screen for tobacco use and integrate tobacco cessation into

prenatal and postpartum care as part of the standard of care. • All health providers should screen for IPV, substance use, depression, and other behavioral or

mental health issues as part of the standard of care.

31

Address substance use during pregnancy• Create or modify existing policies to support pregnant women living with Substance Use Disorder

(SUD). Policies should work to reduce stigma and develop programs that prioritize treatment for pregnant women with SUD.

• Legislative policy should protect pregnant women from discrimination in publicly funded SUD treatment programs.

• Eliminate barriers related to insurance coverage and physical access that prevent citizens from carrying and using Narcan (naloxone). Ensure Narcan is available for over-the-counter purchase in all pharmacies across the state.

• Providers should receive appropriate reimbursement for methadone treatment, home visits, care coordination, and behavioral health screening for women enrolled in Medicaid.

Promote community health and safety• Enforce existing policies that restrict access to weapons, including firearms, for those with severe

mental illness, perpetrators of violent crimes, and those with a known history of IPV.


Increase Access to Data & Medical Records for Committee Review• Healthcare systems and state agencies should work together to integrate electronic health records

(EHR) with vital statistics to allow data abstractors and the PAMR committee access to information needed to perform a more accurate and comprehensive review of maternal deaths. This may require data sharing agreements.

• The PAMR committee should have access to Department of Children and Family Services records to help the committee better understand circumstances surrounding cases, including documented violence in the home.

• Performing autopsies for all maternal deaths would enhance and improve the committee's review process. More information is needed to determine the feasibility and cost of requiring autopsies.

Expand the obstetric healthcare workforce• Legislative policy should ensure insurance coverage for home visiting and doula services.

Improve care coordination• Fear of prosecution by law enforcement can be a barrier to women seeking help for SUD or IPV.

Policies are needed to ensure there are options to manage and treat IPV and SUD without involving law enforcement.

PAMR Committee RecommendationsPolicy

Current Efforts to Reduce Maternal Mortality

32

Selected programs and activities to reduce maternal mortality and morbidity in Louisiana are outlined below.

1. The Louisiana Perinatal Quality Collaborative launched coordinated quality improvement efforts across the state in August 2018. Teams participating in the collaborative work together to improve obstetric care by implementing best practices supported by the Alliance for Innovation in Maternal Health, with national mentorship from the Centers for Disease Control (CDC). Teams use quality improvement tools to implement practice changes that are aligned with national recommendations and those in this report. Quality improvement efforts thus far have focused on hemorrhage, hypertension, risk assessment and monitoring of early warning signs, appropriate escalation of care, and attention to addressing racial disparities, including through the mandated inclusion of patient and community advisors on each facility team. For further information, please visit: ldh.la.gov/LaPQC.

2. Act 497 (2018 Legislative Session) created the Healthy Moms, Healthy Babies Advisory Council. The Council is made up of maternal and child health experts who are committed to addressing racial and ethnic disparities in maternal health outcomes. The Council was charged with the following:

• Incorporate a community-engaged, equity-focused lens into Louisiana programs and campaigns focused on preventing maternal mortality and morbidity.

• Promote safe and equitable care for all mothers and babies in the state. • Issue a report summarizing recommendations around key issues, such as how to collect and utilize

self-reported race and ethnicity data in quality improvement efforts. This report has been published and is available at this link.

To find and read Act 497 in its entirety, visit legis.la.gov.

3. Act 174 (2018 Legislative Session) provided for a pilot program to expand maternal access to treatment of opioid use disorder and optimize management of neonatal opioid withdrawal syndrome. To find and read Act 174 in its entirety, visit legis.la.gov.

4. LA-PAMR launched its enhanced multidisciplinary review process in 2018, in full alignment with national best practices promoted by the CDC. In 2019, Louisiana was one of 25 states to receive funding under the CDC’s Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM) Program. The PAMR committee was expanded to ensure representation from a variety of geographic regions and fields of expertise – including expertise in addressing social determinants of health – and increased inclusion of women and people of color.

5. The Louisiana Department of Health (LDH) hosted the inaugural Maternal Mortality Summit in August 2019. The summit was part of the response to House Resolution (HR) 294 of the 2019 Regular Session, which called for two summits to “take immediate action to address racial disparities in maternal and child health outcomes, and the alarming rate of mortality for Black infants and mothers in Louisiana.” The Maternal Mortality Summit convened public health professionals, providers, policymakers and community leaders focused on improving childbirth outcomes. LDH Breakout sessions focused on legislative strategies to reduce maternal mortality; redesigning maternity care to meet birthing needs; strategies to address the leading causes of mortality, hemorrhage and hypertension; and recommendations for immediate and long-term action. Recommendations resulting from the Summit can be found in the report here.


http://ldh.la.gov/index.cfm/page/3737

http://ldh.la.gov/assets/docs/LegisReports/ACT497RS20183112020.pdf

http://legis.la.gov/Legis/BillInfo.aspx?i=234684

http://www.legis.la.gov/Legis/BillInfo.aspx?i=234157

https://legis.la.gov/legis/ViewDocument.aspx?d=1142983

http://ldh.la.gov/assets/docs/LegisReports/HR294SR240RS20192102020.pdf

Appendices and

References


A. Acronyms

Acronym Definition

BFH Bureau of Family Health

CDC Centers for Disease Control and Prevention

ICD International Classification of Diseases

LaHIDD Louisiana Hospital Inpatient Discharge Database

LaPQC Louisiana Perinatal Quality Collaborative

LDH Louisiana Department of Health

MCH Maternal and Child Health

MMRIA Maternal Mortality Review Information Application

NCHS National Center for Health Statistics

OPH Office of Public Health

PAMR Pregnancy-Associated Mortality Review

WHO World Health Organization


35

In 1992, the Louisiana Department of Health (LDH)-Office of Public Health (OPH)-State Center for Health Statistics (SCHS) initiated the Louisiana Pregnancy Mortality Surveillance System (LPMSS) to investigate the causes of pregnancy-related maternal deaths in order to identify system-level opportunities for prevention. A check box on the Louisiana death certificate identified these deaths through a positive response to the question “If deceased was female 10-49, was she pregnant in the last 90 days?”

LPMSS partnered with the Maternal and Child Health (MCH) Program of OPH in 2000 to gain additional medical expertise in the review of causes of pregnancy-related maternal deaths occurring from 1995 through 1999. The MCH Program Medical Director completed reviews using cause of death listed on maternal death certificates. The Medical Director continued to support LPMSS through an annual review of maternal death cases using information from the death certificate along with any corresponding live birth or fetal death records.

Additional improvements in maternal death identification began in 2006 when LPMSS received technical assistance from the Pregnancy Mortality Surveillance System at the Centers for Disease Control and Prevention (CDC). In addition to using Louisiana Hospital Inpatient Discharge Data (LaHIDD) as an additional data source for identification of maternal deaths, LPMSS also expanded the case definition from pregnancy-related deaths to all pregnancy-associated deaths, or all women who died during pregnancy or within 1 year of pregnancy, irrespective of cause.

In 2007, the MCH Program conducted an evaluation of 2000-2005 LPMSS maternal death records to assess if linkage with LaHIDD data resulted in improved maternal death identification compared to linkages using only vital records death and live birth/fetal death records. The evaluation also examined differences in the number of maternal deaths identified when using different common U.S. and global definitions of maternal mortality. Results highlighted the need to make additional improvements to methodology and procedures pertaining to maternal death review in Louisiana, including the specific recommendation to abstract medical records of all maternal death cases to improve the availability of complete information during the review process.

The MCH Program introduced the Louisiana pregnancy-associated Mortality Review (LA-PAMR) Program in 2010, achieving four new improvements to the Louisiana maternal mortality review process. First, the scope of reviews beginning with 2008 records was broadened to include all pregnancy-associated maternal deaths as defined by the American College of Obstetricians and Gynecologist (ACOG) and CDC definitions.

Second, standardized case identification procedures were documented, including the recommendation to link death certificates of all Louisiana resident women ages 10-55 years with live birth, fetal death, and LaHIDD data. Third, abstraction of medical and coroner records for all maternal deaths was implemented to provide a comprehensive record for case review. And fourth, LA-PAMR became an official activity of the Louisiana Commission on Perinatal Care and the Prevention of Infant Mortality (Louisiana Perinatal Commission), thereby making LA-PAMR records confidential and protecting them from discovery in legal proceedings.


B. HistoryLouisiana Maternal Mortality Review

36

In 2017, recognizing the concern for rising rates of maternal mortality locally and nationally and new opportunities for action and prevention, the LDH-OPH-Bureau of Family Health initiated an intensive review process of maternal deaths occurring between 2011 and 2016. Only pregnancy-related deaths were reviewed for this time period. This decision was made to balance organizational capacity to review and analyze maternal deaths with an urgent need for local data in order to identify new opportunities for action and prevention. This review was needed to produce the following priority items:

• An up-to-date and usable report for public distribution• A more accurate calculation of Louisiana’s maternal mortality ratio• Data-informed recommendations for perinatal quality initiatives, including the Louisiana Perinatal Quality

Collaborative.

The targeted review was restricted to cases of women who were pregnant at the time of death or who died within 42 days of the end of the pregnancy, and whose cause of death is consistent with the World Health Organization’s (WHO) definition of maternal death, quantified by a specific set of International Classification of Diseases 10th revision (ICD-10) codes. Data sources used to produce the case summaries presented in the review meetings included vital records death certificates, live birth or fetal death certificates related to the maternal death, coroner’s reports, hospital records, other medical records, and psychosocial records when possible.

In 2018, the review committee expanded the review process to include all pregnancy-associated deaths starting with deaths that occurred in 2017. The expanded review includes all deaths that occurred while pregnant or within 1 year of the end of pregnancy, regardless of the cause. Including pregnancy-associated cases will:

• Allow for greater understanding of medical and nonmedical contributors to death• Prioritize interventions that may reduce maternal deaths• Allow for the most accurate identification and comprehensive review of deaths• Allow specific recommendations for actions to inform local, state and national prevention strategies


B. History (continued)Louisiana Maternal Mortality Review

C. Data Sources and MethodologyLouisiana Pregnancy-Associated Mortality Review

37

Vital Records Data and Linkage MethodologyLouisiana Vital Records death certificates were used to identify deaths occurring from January 1, 2017 through December 31, 2017 to women ages 10-55 years old who were Louisiana residents at the time of death, and whose deaths occurred in Louisiana. All pregnancy-associated cases (see pg. 3 for definitions) were eligible for review.

Deaths were identified through a combination of linkages, the pregnancy checkbox on death certificates, and obstetric code (O-code) causes of deaths. Deaths were identified in four steps:

1. Data linkages: Death certificates of women of childbearing age were linked to infant birth and fetal death certificates. Variables used to create these linkages include: mother’s social security number, mother’s date of birth, infant/fetal date of delivery, mother’s first and last name, and child’s last name (some linkages were made using soundex, a phonetic algorithm for indexing names by sound so they can be linked despite minor differences in spelling). SAS version 9.4 was used in conjunction with the LinkPro macro and Link King to complete all linkages.

2. Pregnancy checkbox: Death certificates with the pregnancy checkbox filled in, indicating that the woman was pregnant at the time of death or within one year of pregnancy, were identified as maternal deaths.

3. O-codes: Deaths of women where the ICD-10 code for underlying cause of death was in chapter O were identified as potential pregnancy-associated deaths.

4. Louisiana Hospital Inpatient Discharge Database (LaHIDD) linkages: Linkages between death records and hospital discharge records (LaHIDD) were conducted to identify additional cases. All women between the ages of 10 and 55 who had any pregnancy-related ICD-10CM codes were included. Variables used to link the death file with the LaHIDD file included mother's social security number, mother's date of birth, and mother's first and last name. Women who were found to have a delivery, positive pregnancy test, or an ectopic pregnancy were added to the list of maternal deaths. LAHIDD linkages were conducted using Link Plus and Link King software.

Potential pregnancy-associated deaths identified using the pregnancy checkbox and O-codes required verification by the Bureau of Family Health’s Maternal and Child Health (MCH) Coordinators (see Appendix F). Validation requires individuals submitting data to verify that a woman was indeed pregnant at the time of death, or within one year. Validation is designed to reduce the number of “false positive” identifications of pregnancy-associated deaths that result from the pregnancy checkbox being checked in error.

Verification of Eligibility and Record AbstractionMCH Coordinators (nurses) received an Excel file of potential pregnancy-associated deaths identified through Vital Records data that occurred within their geographic coverage area. The file was posted to a secure server and contained each woman’s first and last name, date of birth, date of death, ICD-10 cause of death, location or hospital where the death occurred, and, where available, information related to the delivery of the fetus or infant. A death was considered “verified,” and therefore eligible for review, if the MCH Coordinator confirmed a pregnancy within 1 year of death based on medical records or coroner reports. MCH Coordinators then abstracted available medical records and/or coroner reports for all verified pregnancy-associated deaths using an abstraction form developed by Louisiana clinicians and including sections thought to be most relevant to the outcome of each case (See Appendix H).


Methodology & Guidelines for Reviewing Maternal DeathsA multi-disciplinary Maternal Mortality Review Committee reviewed the 65 verified cases (see Appendix D). All committee members signed a confidentiality form prior to receiving de-identified case summaries. Anyone with personal knowledge of a particular case did not share details beyond the record abstraction. A summary of each case was presented by the review committee Chair, followed by open forum, then structured discussions. The committee used the Building U.S. Capacity to Review and Prevent Maternal Deaths project’s Maternal Mortality Review Information Application’s (MMRIA) Committee Decisions Form (version 14) to classify each case (see Appendix E).

Data LimitationsMethods to identify maternal deaths on the Vital Records death certificate can lead to:• Correct identification of a maternal death.• Incorrect identification of maternal death due to:

o Reporting a maternal death in error (false case): a recent pregnancy (defined as either pregnant at the time of death; pregnant within 42 days of death; or pregnant within 43 days to 1 year prior to death) on the death certificate that cannot be confirmed through medical records or coroner reports.

o Failing to identify a true case (missed case): any woman who was pregnant or recently pregnant based on the definitions above at the time of death.

Potential reasons for missed cases include, but are not limited to:• Early pregnancies that were not known or detected at the time of death.• Recent miscarriages, other pregnancy terminations, or fetal deaths that were not known or detected at the

time of death. • Failing to identify a live birth or fetal death record associated with a woman who was pregnant or had

recently delivered at the time of death.• Missing or delayed data linkage between maternal deaths and live births for mothers whose infants were

adopted.

Classification based on ICD-10 O-codes or the pregnancy checkbox alone, without full record review, are more likely to result in misclassification. The ability to classify these deaths relies heavily on the availability of medical and coroner records. Even a complete history from medical records and/or coroner reports does not guarantee that a determination can be made.

Aggregate data based on counts less than 20 are considered unstable and should be interpreted with caution; these numbers, percentages, ratios or rates may change considerably from one time period to the next.


C. Data Sources and MethodologyLouisiana Pregnancy-Associated Mortality Review

D. 2017 PAMR Committee

Name Role and Organization

Alfred Robichaux, MD Maternal Fetal Medicine, Ochsner Health System

Arwen Podesta, MDPsychiatry, Addiction Medicine, Podesta Psychiatry, Tulane University

Bridget Gardner, RN Director, Injury Prevention Program, University Medical Center

Cheri Johnson, RNC-OB, MSN Perinatal Health and Nursing, Woman’s Hospital

Devin George, MPA Director, Vital Records, Louisiana Department of Health

Emily Stevens, MSW, MBA Director of Care Management, Woman’s Hospital

Erin O’Sullivan, MD Forensic Pathology, Orleans Parish Coroner’s Office

Eva Lessinger, MSW Director, New Orleans Family Justice Center

Floyd Roberts, MD Clinical Affairs, Louisiana Hospital Association

Gabriella Pridjian, MD Maternal Fetal Medicine, Tulane Hospital

Helen Hurst, DNP, RNC, APRN Director of Nursing, University of Lafayette

Ivory Wilson, MA Behavioral Health, Louisiana Department of Health

Jane Martin, MD Maternal and Fetal Medicine Fellow, Ochsner Health System

Jennifer Avegno, MDDirector, City of New Orleans Health Department Emergency Medicine, University Medical Center

Joseph Biggio, MD Maternal Fetal Medicine, Ochsner Health System

Karli Boggs, MD Obstetrics and Gynecology, Woman’s Hospital

Kerrie Redmond, BSN, MSNLouisiana Perinatal Quality Collaborative, Louisiana Department of Health

Latona Giwa, BSN, MPH Birthmark Doula Collective

Lisa Freeman, JD Director, Louisiana Highway Safety Commission

Mariah Wineski, MS Director, LA Coalition Against Domestic Violence

Marshall St. Amant, MD Maternal Fetal Medicine, Woman’s Hospital

Murtuza “Zee” Ali, MD Cardiology, Louisiana State University

Nicole Deggins, CNM, MSN, MPH Director, Sista Midwife

Nikki Greenway, MSN, IBCLC NOLA Breastfeeding Center


Name Role and Organization

Pooja Mehta, MD, MSHP(Medical Director, 2017-2018)

Obstetrics and Gynecology, Louisiana State University HealthSciences Center New Orleans

Robert Maupin, MDMaternal Fetal Medicine, Louisiana State University Health Sciences Center New Orleans

Rodney Wise, MD Medical Officer, AmeriHealth Caritas

Scott Barrilleaux, MDMaternal Fetal Medicine, Louisiana Commission on Perinatal Care and Prevention of Infant Mortality

Shakira Herbert, MSW, RSWChild Welfare Programs, Department of Children and Family Services

Stephen Phillipe, MS, EMT-P State Emergency Medical Services

Veronica Gillispie-Bell, MD, FACOG(Medical Director, current)

Louisiana Perinatal Quality Collaborative and Pregnancy Associated Mortality Review


D. 2017 PAMR Committee

E. MMRIA Committee Decisions Form

41

MATERNAL MORTALITY REVIEW INFORMATION APPLICATION (MMRIA)

Committee Decisions Form – Page 1

Additional information about MMRIA can be found at reviewtoaction.org/implement/mmria#collapseThree-mmria


http://reviewtoaction.org/implement/mmria#collapseThree-mmria


42







43







44






F. Regional Maternal and Child Health

Coordinators and Mortality Surveillance Team

45

Region Staff

Region 1 Rosa Bustamante-Forest, APRN, MPH

Region 2 Kelly Bankston, BSN, RN

Region 3 Nicole Soudelier, BSN, RN

Region 4 Debra Feller, BSN, RN

Region 5 Jade Marler, RN, CIC

Region 6 Lisa Norman, BSN, RN

Region 7 Shelley Ryan-Gray, BSN, RN

Region 8 Sara Dickerson, RN

Region 9 Martha Hennegan, RN

StatewideRosaria Trichilo, MPH (current)

Robin Gruenfeld, MPH (2014-2018)

Mortality Surveillance Epidemiologist Jia Benno, MPH

Program Support Karen Webb


G. Pregnancy Mortality Surveillance System

(PMSS) Cause of Death Categorizations

PMSS Cause of Death Explanation / Included Conditions

Amniotic Fluid Embolism ----

Autoimmune DiseasesSystemic lupus erythematosus, Other collagen vascular diseases/Not otherwise specified

Blood DisordersSickle cell anemia, Other hematologic conditions including thrombophilias/Thrombotic thrombocytopenic purpura/Hemolytic uremic syndrome/Not otherwise specified

CardiomyopathyPostpartum/peripartum cardiomyopathy, Hypertrophic cardiomyopathy, Other cardiomyopathy/Not otherwise specified

Cardiovascular and Coronary Conditions

Coronary artery disease/Myocardial infarction/Atherosclerotic cardiovascular disease, Pulmonary hypertension, Valvular heart disease, Vascular aneurysm/Dissection, Hypertensive cardiovascular disease, Marfan’s syndrome, Conduction defects/Arrhythmias, Vascular malformations outside the head and coronary arteries, Other cardiovascular disease, including congestive heart failure, cardiomegaly, cardiac hypertrophy, cardiac fibrosis, and non-acute myocarditis/Not otherwise specified

Cerebrovascular AccidentsHemorrhage/thrombosis/aneurysm/malformation, but not secondary to hypertensive disease

Conditions Unique to Pregnancye.g., Gestational diabetes, Hyperemesis, Liver disease of pregnancy

EmbolismThrombotic (non-cerebral), Other embolism/Not otherwise specified

Hemorrhage

Rupture/Laceration/Intra-abdominal bleeding; Placental abruption, Placenta previa, Ruptured ectopic pregnancy, uterine atony/ postpartum hemorrhage, Placenta accreta/increta/percreta, due to retained placenta, due to primary disseminated intravascular coagulation, Other hemorrhage/not otherwise specified

Infection

Postpartum genital tract (e.g., of the uterus/pelvis/perineum/ necrotizing fasciitis), Sepsis/septic shock, Chorioamnionitis/ antepartum infection, Non-pelvic infections (e.g., pneumonia, H1N1, meningitis, HIV), Urinary tract infection, Other infections/Not otherwise specified


G. Pregnancy Mortality Surveillance System

(PMSS) Cause of Death Categorizations

PMSS Cause of Death Explanation / Included Conditions

Liver and Gastrointestinal Conditions

Crohn’s disease/Ulcerative colitis, Liver disease/failure/transplant, Other gastrointestinal diseases/Not otherwise specified

MalignanciesGestational trophoblastic disease, Malignant melanoma, Other malignancies/Not otherwise specified

Metabolic/Endocrine Conditions Obesity, Diabetes mellitus, Other metabolic/Endocrine disorders/Not otherwise specified

Preeclampsia and Eclampsia ----

Pulmonary Conditions (Excluding Adult Respiratory Distress Syndrome)

Chronic lung disease, Cystic fibrosis, Asthma, Other pulmonary disease/Not otherwise specified

Renal Diseases ----

Seizure DisordersEpilepsy/seizure disorder, Other neurologic diseases/Not otherwise specified

Unknown ----

47

PMSS Cause of Death Categorizations available at: reviewtoaction.org/sites/default/files/national-portal-material/Report%20from%20Nine%20MMRCs%20final%20edit.pdf


http://www.reviewtoaction.org/sites/default/files/national-portal-material/Report%20from%20Nine%20MMRCs%20final%20edit.pdf

H. Maternal Death Abstraction Form

48

Demographic Information Abstracted Information

ID#

Maternal Age

Ethnicity

Gravidity

Parity

Insurance status

Pregnancy Abstracted Information

Time between conception and diagnosis of pregnancy

Number of prenatal appointments

Medications

PMH / PSH

Family History

Fetal Presentation

Multiple births

Placental location

Pre-pregnancy weight of first booking weight

Height (if recorded) and calculated BMI

Lifestyle factors

Birth attendant

Termination of Pregnancy (TOP)

Lowest Hb

Glucose screen

Research studies


H. Maternal Death Abstraction Form

49

Pregnancy (continued) Abstracted Information

Complications of pregnancy

Interventions – early pregnancy (evacuation, laparotomy,

hysterectomy, transfusion)

Interventions – antenatal (transfusion, version)

If death occurred antepartum; gestational age at death

Labor / Delivery Abstracted Information

Type of labor (spontaneous, augmented, induced, no labor, no

specified)

Interventions – intrapartum (instrument delivery, symphysiotomy,

cesarean, hysterectomy, transfusion)

Complications of delivery

Method of delivery

Pain relief during labor

Live birth / still birth

Puerperium / late maternal stage / general Abstracted Information

Interventions – post-partum (evacuation, laparotomy,

hysterectomy, transfusion, manual removal, return to OT)

Interventions – other (general anesthetic, epidural, spinal

anesthetic, local anesthetic, ICU / CCU, ventilation)

Cause of death Abstracted Information

If death occurred post-partum; number of days post-partum at

death

Classification of death (ICD-10)

Avoidable factors

Additional comments

Note: The additional comments section was used to add any information not contained in any other specific section of the form that the nurse deemed relevant to complete case abstraction


References

50

1. Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion (2020, February 4). Pregnancy Mortality Surveillance System. Retrieved from https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Freproductivehealth%2Fmaternalinfanthealth%2Fpregnancy-mortality-surveillance-system.htm

2. Amnesty International Publications. (2010). Deadly delivery: the maternal healthcare crisis in the USA. Retrieved from Amnesty International Secretariat Website: http://www.amnestyusa.org/sites/default/files/pdfs/deadlydelivery.pdf

3. Hunt, P., & Bueno de Mesquita., J. (2010). Reducing maternal mortality –the contribution of the right to the highest attainable standard of health. Retrieved from https://www.unfpa.org/sites/default/files/pub-pdf/reducing_mm.pdf

4. Building U.S. Capacity to Review and Prevent Maternal Deaths. (2018). Report from nine maternal mortality review committees. Retrieved from http://reviewtoaction.org/Report_from_Nine_MMRCs

5. Kieltyka L, Mehta P, Schoellmann, K, Lake C, Zapata A, Herwehe J, Gruenfeld R, Plante L. Louisiana Maternal Mortality Review Report 2011-2016. (2018). Louisiana Department of Health. Retrieved from http://ldh.la.gov/assets/oph/Center-PHCH/Center-PH/maternal/2011-2016_MMR_Report_FINAL.pdf.

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9. Gadson, A., Akpovi, E., & Mehta, P.K. Exploring the social determinants of racial/ethnic disparities in prenatal care utilization and maternal outcome. Seminars in Perinatology, 2017; 41(5), 308-317. doi:10.1053/j.semperi.2017.04.008

10. Wheeler SM, Bryant AS. Racial and Ethnic Disparities in Health and healthcare. Obstet Gynecol Clin North Am. 2017;44(1):1‐11. doi:10.1016/j.ogc.2016.10.001

11. Louisiana PRAMS Data Report 2017. Louisiana Pregnancy Risk Assessment Monitoring System. Louisiana Department of Health. Retrieved from https://partnersforfamilyhealth.org/wp-content/uploads/2019/02/2017PRAMSDataReport_final.pdf

12. St. Pierre A, Zaharatos J, Goodman D, Callaghan W. Challenges and Opportunities in Identifying, Reviewing and Preventing Maternal Deaths (2018). Obstetrics & Gynecology, 131:138-142. doi: 10.1097/aog.0000000000002417.

13. Committee on Obstetric Practice (2017). Committee Opinion No. 711: Opioid Use and Opioid Use Disorder in Pregnancy. Obstetrics and gynecology, 130(2), e81–e94. https://doi.org/10.1097/AOG.0000000000002235

14. Krans, E. E., Campopiano, M., Cleveland, L. M., Goodman, D., Kilday, D., Kendig, S., Leffert, L. R., Main, E. K., Mitchell, K. T., OʼGurek, D. T., DʼOria, R., McDaniel, D., & Terplan, M. (2019). National Partnership for Maternal Safety: Consensus Bundle on Obstetric Care for Women With Opioid Use Disorder. Obstetrics and gynecology, 134(2), 365–375. https://doi.org/10.1097/AOG.0000000000003381

15. ACOG Practice Bulletin No. 202: Gestational Hypertension and Preeclampsia. (2019). Obstetrics and gynecology, 133(1), e1–e25. https://doi.org/10.1097/AOG.0000000000003018

16. American College of Obstetricians and Gynecologists (2015). Patient Safety Bundle: Maternal Venous Thromboembolism (+AIM). Council on Patient Safety in Women’s healthcare. https://safehealthcareforeverywoman.org/patient-safety-bundles/maternal-venous-thromboembolism/


https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm?CDC_AA_refVal=https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregnancy-mortality-surveillance-system.htm

https://www.cdc.gov/nchs/data/vsrr/report004.Pdf

https://partnersforfamilyhealth.org/wp-content/uploads/2019/02/2017PRAMSDataReport_final.pdf

https://doi.org/10.1097/AOG.0000000000002235

https://doi.org/10.1097/AOG.0000000000003381

https://doi.org/10.1097/AOG.0000000000003018

https://safehealthcareforeverywoman.org/patient-safety-bundles/maternal-venous-thromboembolism/

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19. Hillemeier, M. M., Domino, M. E., Wells, R., Goyal, R. K., Kum, H. C., Cilenti, D., & Basu, A. (2018). Does Maternity Care Coordination Influence Perinatal healthcare Utilization? Evidence from North Carolina. Health services research, 53(4), 2368–2383. https://doi.org/10.1111/1475-6773.12742

20. Rutledge, R. I., Domino, M. E., Hillemeier, M. M., & Wells, R. (2016). The effect of maternity care coordination services on utilization of postpartum contraceptive services. Contraception, 94(5), 541–547. https://doi.org/10.1016/j.contraception.2016.06.007

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